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Centene Corporation
Founded as a single health plan in 1984, Centene Corporation (Centene) has established itself as a national leader in the healthcare services field. Today, through a comprehensive portfolio of innovative solutions, we remain deeply committed to delivering results for our stakeholders: state governments, members, providers, uninsured individuals and families, and other healthcare and commercial organizations. Read More
Address | Centene Corporation Centene Plaza 7700 Forsyth Blvd. St. Louis, MO 63105 |
Website | www.centene.com/ |
Holding | No Holding Details |
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Nurse
Position Purpose:
Facilitate medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met
Knowledge/Experience:
LPN with 3+ years of clinical nursing experience or RN with 2+ years of clinical nursing experience. Utilization or appeals review experience preferred. Knowledge of InterQual criteria preferred. Proficient with Microsoft Office applications.
Licenses/Certifications: Current state’s RN or LPN license.
Position Responsibilities:
• Review clinical data to determine claim payment based on company policies and National Committee for Quality Assurance (NCQA) guidelines, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review
• Prepare case review for the Medical Director in cases where criteria are not met based on the additional clinical information received
• Generate appropriate appeal resolution communication to the member and provider in accordance with company policies and NCQA guidelines. Create system authorization events for overturned denial decisions
• Request additional information, as appropriate from provider(s) to facilitate timely appeals resolution
• Gather and prepare case information for Administrative Law Hearings
• Maintain appeals process within the prescribed NCQA timeframes and appeals turnaround database
• Assist the Medical Director with revising, updating and/or creating new policies to satisfy NCQA and contractual requirements
Other Job Information
Vacancy type: |
Full Time | Contact Mode: |
not provided |
Fax: |
not provided | Contact Name: |
not provided |
Job Duration: |
not provided | Phone: |
(314) 725-4477 |
Email: |
not provided |
TalentOne Job Information
Healthcare Nurse
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